Main factors affecting the system

• Cross Section of Risk Factors - close living quarters, shared staff and services, and high medical frailty of patients.

• Rapid Growth - In 30 years, the population in Texas over the age of 65 will triple. Those over 85 will quadruple by 2050.

• Highly Regulated - The Nursing Home Reform Act of 1987 as well as thousands more federal, state and local level codes.

Areas for intervention

1. Infection control protocols

2. Actions and behaviors of staff

3. Design and management of facilities

Initial Pilot - infection control protocols

Following in-field primary research studies, an initial infection control pilot was launched - centering on a three-part entry protocol: stop, hand sanitize, replace gloves and mask. Visual cues at each patient room door reinforced the steps. The pilot produced no measurable reduction in COVID infection rates.

Researcher observations revealed that staff were routinely bypassing the protocol entirely. Post-pilot interviews surfaced the root cause: despite training, staff harbored deep frustration toward their work environment. They felt overworked, underpaid, and invisible to leadership — and that dissatisfaction translated directly into non-compliance.

The data confirmed the scale of the problem. Median annual turnover for Certified Nursing Aides in Texas was 85%, with many facilities exceeding 100% per year — a cycle that made institutional knowledge, and therefore infection control, impossible to sustain.

This reframed the problem entirely. Protocols weren't failing because of bad design — they were failing because of a broken relationship between staff and their workplace. That had to be addressed first.

Causal flow diagram | Depicts underlying forces at play

Second Pilot - Targeting Latent Workforce Conditions

The design brief

Two guiding questions shaped our approach: How might we help staff feel valued and supported? How might we help staff recharge throughout their shift?

Primary research revealed that most facilities lacked any dedicated space for staff to rest and recover between shifts — a gap that compounded existing dissatisfaction and accelerated attrition. During COVID-19, when occupational stress reached unprecedented levels, the absence of these spaces became critical.

The solution - Decompression zones

The intervention was clear: create a dedicated staff recovery space inside facilities where none existed. The solution had to work within minimal budgets, adapt to highly variable floor plans, and be simple enough for volunteer organizations to implement independently. And given the intensity of the work environment, the space had to maximize psychological recovery in the shortest possible time.

This led to the development of a scalable, custom-designed decompression zone framework — deployable across regulated care facilities without dedicated design staff or significant capital investment.

Facility B

An unused “spa” room

Facility B was in many ways a more challenging space. Although we did not need to accommodate other uses of the space as a lunchroom, etc. our design needed to accommodate an out-of-use toilet and bathtub. These two items were not in use, but could not be removed from the space. We decided to use inexpensive foam panels and bamboo fencing to conceal the objects. Our budget for this space was $400 and we were able to introduce more textural items, like rugs and pillows to make the space more cozy. We used two chairs the facility had onsite and purchased two additional stools to increase seating capacity.